APPLICATION FOR CONTRACTORS PROFESSIONAL LIABILITY COVERAGE

Transcription

1 55 Water Street 23 rd Floor New York, NY Tel (212) Fax (212) APPLICATION FOR CONTRACTORS PROFESSIONAL LIABILITY COVERAGE This is an application for a Claims Made and Reported policy. This application is not a binder. Notice: The insurance coverage for which you are applying is written on a Claims Made and Reported policy. Only claims that are first made against you during the policy year and reported to us within that policy year, or within 60 days after the end of the policy year, are covered, subject to policy provisions. The limits of liability available to pay damages, including judgment or settlement amounts, shall be reduced by amounts incurred for claims expenses. Further note that amounts incurred for claims expenses and damages shall also be applied against the deductible amount. 1. Firm Information Name of Firm Contact Name Principal Office Address Phone # Fax # Address Website Address FEIN # 2. Sole Proprietorship Partnership Corporation Other 3. Date the firm was established 4. List branch office locations (if any) and the percentage of fees derived from each location. City, State Last Fiscal Year Fees 5. List any pre-existing or related entities and subsidiaries, their relationship or percentage of ownership, dates of existence and services provided. If coverage is desired for the entity, please list the retro date on their current professional liability coverage. LSI-AEX-CPR-APP001 (05/2015) Page 1 of 8

2 6. Provide the number of personnel in each of the following categories Number employed Principals, Partners, Officers & Directors Licensed Design Professionals Technical Personnel Supervisors / Superintendents Construction Managers All Others (please describe): Total number of employees Show the number of employees who left the firm in the past 12 months. Management Professional Staff Number Registered/Licensed Please attach resumes for Principals, Partners and key personnel. 7. Please provide the following information regarding Construction Revenues and Professional Fees. Professional Fees means the exact dollar amount of gross receipts from Professional Services including fees paid to subconsultants, however, excluding direct reimbursables by contract (i.e., travel, per diem, reproduction costs, etc) REVENUE BREAKDOWN Construction and Service Revenues Projection For Current Fiscal Year Professional Fees Projection For Current Fiscal Year Construction and Service Revenues Last Complete Year Build only (no design) $ N/A $ N/A Professional Fees Billed Last Complete Year Operation and Management Services Design-Build (where you do the design in-house) Design-Build (where you hire a design firm) Construction Management At Risk Construction Management Agency $ N/A $ N/A $ $ $ $ $ $ $ $ $ $ $ $ N/A $ N/A $ Design Only N/A $ N/A $ Other Professional Services (provide details below): N/A $ N/A $ TOTAL $ $ $ $ Please identify total Professional Fees: Two Years Ago $ Three Years Ago $ 8. What percentage of your work is hard-bid vs. negotiated 9. Does your firm have any equity interest in any project? yes no ; if Yes, please describe below: LSI-AEX-CPR-APP001 (05/2015) Page 2 of 8

3 10. Have the services provided by your firm changed in the last three years? yes no 11. Please identify the percentage of fees earned on projects by dollar size: Up to $1,000,000 $1,000,000 to $25,000,000 $25,000,000 to $100,000, 000 Over $1,000,000, Please identify the percentage of services rendered: US Canada Other If Other, Where? 13. Please indicate the approximate percentage of last fiscal year gross receipts in the disciplines below. Acoustical Engineering Geotechnical Laboratory analysis Architectural Planning Illumination Engineering Architecture Interior Design and Graphics Civil WWTP Labs Other Civil Engineering Landscape Architecture CM Agency Mechanical Engineering CM At Risk Process Engineering Electrical Engineering Structural Engineering Environmental Engineering Surveyor Environmental Science Traffic Engineering Geotechnical Drilling Other: Geotechnical Engineering Must Total What percentage of the firm s last fiscal year gross receipts were paid to subconsultants in the following disciplines: Insured for Professional Liability Uninsured a. Structural b. Environmental Services c. Other professional services 15. Agreements a. What percentage of subconsultants provide evidence of professional liability insurance? b. What limit of liability do you require? c. What percentage of subcontractors provide evidence of additional insured status for you? d. What percentage of your sub agreements include hold harmless agreements? e. Does the firm have a procedure to update subconsultant certificates annually? yes no 16. a. Does any one contract or client represent more than 50 of the firm s last fiscal year gross revenues? If yes, please describe below yes no LSI-AEX-CPR-APP001 (05/2015) Page 3 of 8

4 b. What percentage of revenues is derived from repeat clients? 17. Indicate the percentage of last fiscal year gross receipts derived from each of the following types of clients: Owners Local Governments Developers State Governments Contractors Federal Government Design Professionals Foreign Environmental Consultants Other 18. Indicate the percentage of last fiscal year professional services attributable to the following services: Design with construction observation/review Design without construction observation/review Construction observation/review without design Feasibility, economic, seismic or forensic studies or reports Conceptual, schematic, or other design without construction documents Abandoned projects Operation and Management Services Program Management or other non-design related services Plan checking without design Quantity or cost estimates without design Inspection as a stand-alone service or property condition assessments Boundary and construction staking 19. Please specify the types of contracts used by the firm in the last fiscal year. Firm s own standard contract Purchase order forms Standard industry contract (AIA, EJCDC, DBIA, AGC) Verbal agreements Letter of agreement Other Client contract a) Who at your firm negotiates agreement? Title: b) Do you follow contractual procedures for change orders? yes no 20. Has the firm provided professional services for condominium projects in the last ten years? yes no If yes, please complete a condominium questionnaire. 21. Indicate the percentage of last fiscal year gross receipts derived from each of the following types of projects: Airport runways Motels All other environmental projects Offices, warehouses Apartments Oil refineries Bridges, trestles Parking garages Chemical plants and pipelines Parks Churches Processing, manufacturing and production buildings Colleges and universities Processing, manufacturing and production systems Correctional institutions Residential condominiums Custom homes Restaurants Dams, reservoirs, levees Retail, malls, shopping centers LSI-AEX-CPR-APP001 (05/2015) Page 4 of 8

5 Facilities related to nuclear activities Roads and highways Harbors, docks, piers, or structures for offshore use Single family residential subdivisions High rise all buildings over 15 stories Ski lifts, amusement rides, amusement parks Hospitals, retirement homes, convalescent Sports facilities, arenas, convention homes facilities, grandstands, theaters Hotels Transportation passenger terminals K-12 schools Utilities Landfills Waste treatment, storage or disposal facilities Mines, quarries, tunnels Wastewater, sewage and water treatment systems Mold remediation Other Please submit a project list outlining the firm s 5 largest projects with this application. Must Total If your firm involved in any Integrated Project Delivery (IPD) or Public-Private Partnerships (P3)? yes no If Yes, please describe below: 23. Please describe any limitation of liability provisions in your contracts, including but limited to, Condo Conversion Disclaimer/Waiver (or similar): 24. Does your firm provide any risk management or educational programs for your staff / managers? yes no 25. Does the firm follow written: a) in-house quality control yes no b) health & safety procedures? yes no If yes, please indicate the last date they were updated. 26. Is the firm or any principal involved in real estate development or ownership? yes no 27. Has the firm become involved in the manufacture, fabrication, sale, leasing or distribution of any product, process, component, device or system? yes no 28. Has the firm designed a building, component or system which might be used on more than one project without services for site adaptation? yes no 29. Has the firm entered into a joint venture agreement with an entity that did not provide design professional services? yes no If you ve answered Yes for questions 26 through 29, please provide details on a separate sheet. 30. In the last five years, have any professional liability claims been made against the firm, its predecessors or any past or present principal, partner, officer, director or employee, or any entity identified in response to questions 1 and 5? yes no If yes, complete the claims questionnaire. LSI-AEX-CPR-APP001 (05/2015) Page 5 of 8

6 31. Does the firm or any of the principals, partners, officers, directors or employees, or any entity identified in response to questions 1 and 5, have knowledge of any act, error, omission, unresolved job dispute, accident or any other circumstance which might reasonably be expected to give rise to a claim under this insurance? yes no If yes, on a separate sheet, list details of this situation including name of project, involved parties and description of circumstance. Any claim arising from any facts, claims, circumstance or situations require to be disclosed in response to questions 30 & 31 above will be excluded from the proposed insurance. 32. Is the firm currently insured for Professional Liability coverage? yes no If yes, please provide the retroactive date on your policy. Provide your insurance history for the past five years below. Company Policy Period Limit Deductible Premium 33. Please identify your General Liability Insurance: Carrier: Policy Period: to Policy Limits: / / Loss Ratio: 34. What is your current Workers Compensation experience modification rate? 35. Has any insurer cancelled or refused to renew any similar insurance to the firm, its members or an entity listed in questions 1and 5 of this application? yes no If yes, please provide details. 36. Describe any pending corporate acquisitions or historical corporate name changes or mergers and acquisitions that have occurred in the past 5 years: 37. Indicate the options the applicant would like quoted for professional liability coverage: Combined Single/Aggregate Limit Split Limits Per Claim Deductible Per Claim/Aggregate $500,000 $500,000/1,000,000 $10,000 $1,000,000 $1,000,000/2,000,000 $15,000 $2,000,000 Other / $20,000 $5,000,000 $25,000 Other $50,000 Other 38. If Contractors Pollution Liability Coverage is desired, please complete a CPL application. LSI-AEX-CPR-APP001 (05/2015) Page 6 of 8

7 NOTICE Notice to Arizona Applicants: For your protection, Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties. Notice to California Applicants: Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties. Notice to Colorado Applicants: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policy holder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies. Notice to Florida and Idaho Applicants: Any person who knowingly and with intent to injure, defraud, or deceive any employer or employee, insurance company or self-insured program files a statement of claim containing any false or misleading information is guilty of a *felony. *Third degree felony in Florida. Notice to Indiana Applicants A person who knowingly and with intent to defraud an insurer files a statement of claim containing any false, incomplete or misleading information commits a felony. Notice to Arkansas, Kentucky, Michigan and New Jersey Applicants: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act which is a crime. Notice to Maine and New Mexico Applicants: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines, or a denial of insurance benefits. Notice to Minnesota Applicants: A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime. Notice to New York Applicants: Any person who knowingly and with intent to defraud any insurance company or other person, files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to exceed five thousand dollars ($5,000) and the stated value of the claim for such violation. Notice to Nevada Applicants: Pursuant to NRS686A.291, any person who knowingly and willfully files a statement of claim that contains any false, incomplete or misleading information concerning a material fact is guilty of a felony. Notice to Ohio Applicants: Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing false or deceptive statement is guilty of insurance fraud. LSI-AEX-CPR-APP001 (05/2015) Page 7 of 8

8 Notice to Oklahoma Applicants: Warning: Any person who knowingly and with intent to defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete, or misleading information is guilty of a felony. Notice to Oregon Applicants: Any person who makes an intentional misstatement that is material to the risk may be found guilty of insurance fraud by a court of law. Notice to Pennsylvania Applicants: Any person who knowingly and with intent to defraud any insurance company or other person, files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalty. Notice to Virginia Applicants: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits. Notice to Louisiana Applicants: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. NOTICE If the information supplied on this application changes between the date of this application and the effective date of the policy, should a policy be issued, the applicant will immediately notify the Insurer of such changes, and the Insurer may withdraw or modify any outstanding quotations and/or authorizations or agreement to bind this insurance. The Insurer also reserves the right to modify the final terms and conditions upon review of the completed application and any other information requested by the underwriter herein. If such material change in the risk is discovered after binding, the insurance coverage will be void ab initio ( from the beginning ). The Insurer is a surplus lines insurer, is not licensed by the State and is subject to limited regulation. In the event of insolvency of the Insurer, the insurance is not covered by the State s guaranty fund. This policy may be subject to surplus lines taxes, stamping fees, surcharges, and certain surplus lines reporting requirements mandated by state regulations. The Surplus Lines Broker is responsible for the disclosure of all related taxes, surcharges, and fees. The Surplus Lines Broker is also responsible for the applicable surplus lines reporting requirements including but not limited to the submission of diligent search forms. On behalf of our firm, I agree that this application is true to the best of my knowledge and that I have not suppressed or misstated any material facts and I agree that this application shall be the basis of the contract with the insurance company. It is understood and agreed that the completion of this application does not bind the insurance company to sell nor the applicant to purchase the insurance. Signature Date Name of Principal, Partner or Officer Title LSI-AEX-CPR-APP001 (05/2015) Page 8 of 8